NursingPlex
    Sign In
    ATI LPN comprehensive predictor 2023 retake proctored exam

    A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk. B. Holding gentle, direct pressure on the protruding organ is incorrect. Applying pressure can cause further damage to the exposed tissue and increase the risk of complications. Instead, the focus should be on protecting the organs and minimizing contamination. C. Placing the client’s knees in an extended position is incorrect. Keeping the knees straight can increase tension on the wound. Instead, the nurse should position the client with the knees slightly flexed to reduce strain on the abdominal incision. D. Raising the head of the bed to a 45° angle is incorrect. A high Fowler’s position can increase pressure on the wound. The nurse should place the client in a low Fowler’s position (supine with knees slightly flexed. to reduce tension and prevent further protrusion.

    🔒 Submit your answer to reveal